Download Hypertension Algorithm Update

Hypertension
Mohammad Garakyaraghi,MD
Cardiologist
Associate Professor
 Hypertension
is the most common
condition in primary care.
1
in 3 patients have hypertension
according to NHLBI
 Risk
factor for MI, CVA, ARF,
death






National Institute for Health and Clinical Excellence
(NICE), 2011
Kidney Disease: Improving Global Outcome (KDIGO),
2012
European Society of Hypertension/European Society
of Cardiology, (ESH/ESC), 2013
American Diabetes Association (ADA), 2014
American Society of Hypertension and the
International Society of Hypertension (ASH/ISH),
2014
Eighth Joint National Committee (JNC8), 2013

Limited to RCT’s
◦
◦
◦
◦

Hypertensive adults > 18 years old
Sample size > 100
Follow-up > 1 year
Reported effect of treatment on important health
outcomes (mortality, MI, HF, CVA, ESRD)
January 1966 to December 2009
◦ Separate criteria used of RCT’s published after
December 2009

RCT’s December 2009 – August 2013
1. Major study in hypertension

ACCORD, NEJM 2010
2. > 2,000 participants
3. Multicentered
4. Met all other inclusion/exclusion criteria



Excluded sample size < 100 and f/up period <
1 year
Only included randomized, controlled trials
rated as good or fair
Only included studies reporting effects of
interventions on:
◦
◦
◦
◦
◦
◦
MI
Stroke
ESRD, doubling of Scr, or halving of GFR
Heart failure (HF) or hospitalization for HF
Coronary revascularization or other revascularization
Mortality (Overall mortality, CVD-related mortality, CKDrelated mortality)
A – Strong evidence
B – Moderate evidence
C – Weak evidence
D – Against
E – Expert Opinion
N – No recommendation
JNC8: Strength of Recommendation
Grade
Strength of Recommendation
A
Strong: High certainty net benefit is substantial
Moderate
B
• Moderate certainty net benefit is moderate to substantial, or
• High certainty that net benefit is moderate
C
E
Weak: At least moderate certainty of small net benefit
Expert Opinion
• Insufficient evidence, or
• Evidence is unclear or conflicting
• Further research is recommended in this area



In adults with HTN, does initiating
antihypertensive pharmacologic therapy at
specific BP thresholds improve health outcomes?
In adults with HTN, does treatment with
antihypertensive pharmacologic therapy to a
specified BP goal lead to improvements in health
outcomes?
In adults with HTN, do various antihypertensive
drugs or drug classes differ in comparative
benefits and harms on specific health outcomes?

Age > 60 yo
◦ Systolic:
 Threshold > 150 mmHg
 Goal < 150 mmHg
 LOE: Grade A
◦ Diastolic:
 Threshold > 90 mmHg
 Goal < 90 mmHg
 LOE: Grade A

Age < 60 yo
◦ Systolic:
 Threshold > 140 mmHg
 Goal < 140 mmHg
 LOE: Grade E
◦ Diastolic:
 Threshold > 90 mmHg
 Goal < 90 mmHg
 LOE: Grade A for ages 40-59; Grade E for ages 18-39

Age > 18 yo with CKD or DM
◦ JNC 7: < 130/80 (MDRD NEJM 1994)
◦ Systolic:
 Threshold > 140 mmHg
 Goal < 140 mmHg
 LOE: Grade E
◦ Diastolic:
 Threshold > 90 mmHg
 Goal < 90 mmHg
 LOE: Grade E

Nonblack, including DM
◦ Thiazide diuretic, CCB, ACEI, ARB
 LOE: Grade B

Black, including DM
◦ Thiazide diuretic, CCB
 LOE: Grade B (Grade C for diabetics)

Age > 18 yo with CKD and HTN (regardless of
race or diabetes)
◦ Initial (or add-on) therapy should include an ACEI or
ARB to improve kidney outcomes
 LOE: Grade B
◦ Blacks w/ or w/o proteinuria
 ACEI or ARB as initial therapy (LOE: Grade E)
◦ No evidence for RAS-blockers > 75 yo
 Diuretic is an option for initial therapy

If goal BP not met after 1 month of treatment:
◦ Increase dose of initial drug, or
◦ Add a second drug (Thiazide, CCB, ACEi, or ARB)

If goal BP not met with 2 medications:
◦ Add and titrate a third medication (Thiazide, CCB,
ACEi, or ARB)
◦ Do not use ACE and ARB together

Other classes may be used in the following
scenarios:
◦ Goal BP not met with 3 medications
◦ Contraindication to thiazide, ACE/ARB, or CCB



Titrate to max dose, then add a second
drug
Add a second drug before achieving max
dose of the initial drug
Start with 2 drugs at the same time
◦ If SBP ≥ 160mmHg and/or DBP ≥ 100 mmHg
◦ If SBP ≥ 20mmHg above goal and/or DBP ≥
10mmHg above goal
***Consider scheduling follow-up with the
Enhanced Care Clinic for titration of BP
Meds
Comparison of Recent
Guideline Statements
JNC 8
ESH/ESC
AHA/ACC
ASH/ISH
>140/90
Threshold
>140/90 < 60 yr
Eldery SBP >160
for Drug Rx
>150/90 >60 yr
Consider SBP
>140/90 <80 yr
>140/90
>150/90 >80 yr
140-150 if <80 yr
B-blocker
First line Rx
No
Yes
No
No
Initiate Therapy
>160/100
"Markedly
>160/100
>160/100
Goal BP
Group
General
BP Goal (mm Hg)
DM*
CKD**
JNC 8:
<60 yr: <140/90
>60 yr: <150/90
< 140/90
< 140/90
ESH/ESC:
< 140/90
< 140/85
< 140/90
Elderly
140-150/90
(<80 yr: SBP<140)
ASH/ISH
< 140/90
>80 yr: <150/90
AHA/ACC
< 140/90
*ADA: < 140/80 or lower
(SBP < 130 if proteinuria)
< 140/90
< 140/90
(Consider < 130/80 if proteinuria)
< 140/90
< 140/90
**KDIGO: <140/90 w/o albuminuria
<130/80 if >30 mg/24hr
Comparison of JNC Guidelines
JNC7
JNC8
• Nonsystematic literature
review and expert opinion
• Range of study designs
• No grading system for
recommendations
• Recommendations:
• Systematic review
• Randomized, controlled trials
(RCT) only
• Graded recommendations
• Recommendations:
–
–
–
–
Lifestyle modifications
Initial therapy for HTN
Compelling indications
Addressed secondary HTN
and resistant HTN
– No specific lifestyle
recommendations
– Initial therapy for HTN
– Racial, CKD, and diabetic
subgroups addressed
– Addressed three key questions
Recommendations for
General Population Age ≥ 60 Years
JNC 7
• BP Goal < 140/90 mmHg
(No age recommendations)
JNC8
• BP Goal < 150/90 mmHg
– Rated Grade A
Evidence for JNC8
• HYVET Trial
• SHEP Trial
• JATOS Trial
• VALISH Trial
Recommendations for
General Population Age < 60 Years
JNC 7
• BP Goal < 140/90 mmHg
Evidence for JNC8
• HDFP Trial
• Hypertension-Stroke
JNC8
• SBP Goal < 140 mmHg
– Grade E
• DBP Goal < 90 mmHg
– Ages 30-59 years (Grade A)
– Ages 18-29 years (Grade E)
Cooperative Trial
• MRC Trial
• ANBP Trial
• VA Cooperative Trial
Recommendations for
General Non-black Population
(Including DM)
JNC 7
• First-line: Thiazide diuretics
(no racial distinction made)
JNC8
• First-line
–
–
–
–
Thiazide diuretics
CCB
ACE inhibitor
ARB
• Grade B
Evidence for JNC8
• ALLHAT Trial
• BP control more important
than medication used
• Alpha blockers not
recommended first-line
• LIFE Study
• Beta-blockers not
recommended first-line
• Insufficient evidence to
recommend other classes
Recommendations for
General Black Population (Including
DM)
JNC 7
• First-line: Thiazide diuretics
(no racial distinction made)
JNC8
• Initial treatment for black
population (Grade B) with
DM (Grade C)
– Thiazide diuretics
– CCB
ALLHAT Trial
• Pre-specified subgroup analysis
• Thiazide more effective in
improving CV outcomes
compared to ACEi in black
patient subgroup
• 51% higher rate of stroke (RR
1.51; 95% CI 1.22-1.86) with use
of ACEi as initial therapy in black
patients (compared to CCB)
• 46% of patients in subgroup
analysis had DM
Recommendations for
General Population Age ≥ 18 with CKD
JNC 7
• Goal BP: < 130/80 mmHg
• First-line agent: ACEi or ARB
JNC8
• Goal BP: < 140/90 mmHg
– Grade E
• Initial or add-on treatment:
ACEi or ARB
– Grade B
– Regardless of race or DM
status
Evidence for JNC8
• AASK Trial
• MDRD Trial
• Potential benefit of goal
<130/80 for patients with
proteinuria (>3g/24 hours)
• REIN-2 Trial
• No trials showed goal
<130/80 mmHg significantly
lowered kidney or CV end
points compared to 140/90
Recommendations for
General Population Age ≥ 18 with DM
JNC 7
Evidence for JNC8
• Goal BP: < 130/80 mmHg
• ACCORD-BP Trial
• No difference in outcomes with
SBP < 140 vs. SBP < 120
JNC8
• No good or fair quality trials
• Goal BP: < 140/90 mmHg
– Grade E
to support DBP < 80
2013 ESH/ESC Guidelines for the management of arterial hypertension
Blood pressure goals in hypertensive patients
Recommendations
SBP goal for “most”
•Patients at low–moderate CV risk
•Patients with diabetes
•Consider with previous stroke or TIA
•Consider with CHD
•Consider with diabetic or non-diabetic CKD
<140 mmHg
SBP goal for elderly
•Ages <80 years
•Initial SBP ≥160 mmHg
140-150 mmHg
SBP goal for fit elderly
Aged <80 years
<140 mmHg
SBP goal for elderly >80 years with SBP
•≥160 mmHg
140-150 mmHg
DBP goal for “most”
<90 mmHg
DB goal for patients with diabetes
<85 mmHg
SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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2013 ESH/ESC Guidelines for the management of arterial hypertension
Hypertension treatment for people with diabetes
Recommendations
Additonal considerations
Mandatory: initiate drug treatment in patients
with SBP ≥160 mmHg
• Strongly recommended: start drug treatment
when SBP ≥140 mmHg
SBP goals for patients with diabetes: <140 mmHg
DBP goals for patients with diabetes: <85 mmHg
All hypertension treatment agents are
recommended and may be used in patients with
diabetes
• RAS blockers may be preferred
• Especially in presence of preoteinuria or
microalbuminuria
Choice of hypertension treatment must take comorbidities into account
• Avoid in patients with diabetes
Coadministration of RAS blockers not
recommended
SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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2013 ESH/ESC Guidelines for the management of arterial hypertension
Hypertension treatment for people with nephropathy
Recommendations
Additonal considerations
Consider lowering SBP to <140 mmHg
Consider SBP <130 mmHg with overt proteinuria
• Monitor changes in eGFR
RAS blockers more effective to reduce
albuminuria than other agents
• Indicated in presence of microalbuminuria or
overt proteinuria
Combination therapy usually required to reach BP
goals
• Combine RAS blockers with other agents
Combination of two RAS blockers
• Not recommended
Aldosterone antagonist not recommended in CKD
• Especially in combination with a RAS blocker
• Risk of excessive reduction in renal function,
hyperkalemia
SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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2013 ESH/ESC Guidelines for the management of arterial hypertension
Lifestyle changes for hypertensive patients
Recommendations to reduce BP and/or CV risk factors
Salt intake
Restrict 5-6 g/day
Moderate alcohol intake
Limit to 20-30 g/day men,
10-20 g/day women
Increase vegetable, fruit, low-fat dairy intake
25 kg/m2
BMI goal
Waist circumference goal
Men: <102 cm (40 in.)*
Women: <88 cm (34 in.)*
≥30 min/day, 5-7 days/week
(moderate, dynamic exercise)
Exercise goals
Quit smoking
* Unless contraindicated. BMI, body mass index.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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
Goal BP for patients with DM
◦ Less than 140/80 mmHg
 ACCORD-BP trial
 HOT Trial
 Showed 51% reduction in major CV events in patients with DM
 Post-hoc analysis of small subgroup of the study (not pre-specified)
 Evidence graded as low quality by JNC8

Preferred Agents
◦ ACEi or ARB
 HOPE Study
 Included non-hypertensive patients
 Decreased risk of stroke with ACEi
◦ Despite conflicting evidence, continue to recommend
ACE/ARB first-line
 Cite high CVD risk and high prevalence of undiagnosed CVD in
patients with DM
Thank
You For
Your
Attention